Journal ESWT pada Anak

Journal of Medicine and Life Volume 7, Special Issue 3, 2014

1. Extracorporeal Shockwave Therapy (ESWT) benefits in spastic children with

Cerebral Palsy (CP)

Mirea A* ***, Onose G** ***, Padure L* ***, Rosulescu E****

**Dr. Nicolae Robănescu” National Centre of Neuro-Psychomotor Clinical Rehabilitation,
Bucharest, Romania
**”Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
***“Bagdasar-Arseni” Clinical Emergency Hospital, Bucharest, Romania
****Craiova University, Department of Kinesiotherapy and Sports Medicine, Craiova, Romania

Abstract
Introduction. ESWT refers to the use of Shock Waves in medical practice. It was used as an
important tool in spasticitymanagement of children with CP. The aim of our study was to
evaluate the effect of a 3 session of ESWT on spastic upper and lower limbs muscles in children
with CP.

Methods. Sixty-three children (37 boys and 26 girls), mean age 99.57±53.74 months, were
included in the study. We used focused ESWT, applied in 3 sessions during the admission of
each child, on the mainly affected muscles, using the same parameters on all patients (energy –
0.15 mJ/mm2, shot dose - 500 shocks/ session, frequency - 10 Hz). All patients were assessed
two times: once, in admission (before any physical or ESWT appliance) and second, at discharge
(after receiving the entire prescribed treatment), following: Modified Ashworth Scale (MAS),
Gross Motor Function Classification System (GMFCS), Gross Motor Function Measure
66 (GMFM-66) and also a Questionnaire on Pain caused by spasticity (QPS).

Results. We found a better and significant decrease of MAS level in the ESWT treated group,
thus leading to a concomitant decrease of QPS score and also increase of GMFM-66 score.

Conclusion. ESWT, applied in 3 sessions, with 0.15 mJ/ mm2, using 500 shocks/ min and 10 Hz
as frequency may decrease children spasticity level and pain caused by it and improve the gross
motor function.
Keywords: cerebral palsy, spasticity, shockwave therapy

Material and Methods

Sixty-three children (37 boys and 26 girls), mean age 99.57±53.74 months, were included in the
study. All of the children had a diagnosis of spastic CP. Procedures and measurements were
performed on inpatients of “Dr. Nicolae Robănescu” National Centre of Neuro-Psychomotor
Clinical Rehabilitation, Bucharest, Romania.
The inclusion criteria for all children were the following: (a) informed consent signed by the
parent; (b) age between 2-18 years; (c) diagnosed with spastic CP type; Ashworth score at least
1 and at most 3 in the targeted muscles.
The exclusion criteria were the following: (a) fixed contracture, defined as severe restriction of
the range of joint movement on passive stretch or predominant forms of muscle hypertonia
other than spasticity (i.e., dystonia) in the targeted muscles; (b) severe neurological associated
disorders; (c) pure dyskinetic form of CP; (d) any muscle relaxant medication with peripheral
action (i.e., intrathecal Baclofen) or botulinum toxin administrated within 2 weeks before the
first evaluation and during the study; (e) any changes in the relaxant medication with central
action within 2 weeks before the first evaluation and during the study.

Before the procedures, all parents were carefully informed about ESWT, its effects and side
effects, and all signed an informed consent. The procedure was approved by the Ethics
Committee of “Carol Davila” University of Medicine and Pharmacy. Clinical examination was
performed to assess the effect of the treatment. All children were assessed 2 times
during the study: once, in admission (before any treatment) and second at discharge (after
receiving the entire prescribed and accepted treatment).

The clinical assessment included the following: Modified Ashworth Scale (MAS), Gross Motor
Function Classification System Expanded and Revised (GMFCS E&R) [16], Gross Motor Function
Measure 66 (GMFM-66). The MAS grades spasticity according to six ordinal levels, from 0 ‘normal
muscle tone’, to 4 ‘affected part(s) rigid in flexion or extension’ [17]. The Gross Motor Function
Measure (GMFM) is a clinical tool designed to evaluate change in gross motor function in children
with cerebral palsy, and has become one of the best evaluative measure of motor function
designed for quantifying change in the gross motor abilities of children with cerebral palsy [18].
The pain associated with spasticity was challenging, especially because of children associated
cognitive impairments, or children were too young to be interviewed. In this respect we used an
Adapted Questionnaire on Pain caused by Spasticity (A-QPS), which includes questions and sad/
smiley faces (Wong-Baker FACES) to quantify pain intensity answers [19]. Thirteen pairs (children
and parents) were enrolled for the cognitive interviews. The A-QPS included the following 5
modules (pain evaluation sections): (1) “Think of today and tell me if you feel any tension in the
shoulder, arm, wrist, hip or foot. Please tell me how much you hurt. Below are some faces. Can
you tell me which one shows best how much you hurt?”; (2) “Think of today, when you did not
do anything special, just sit down/ watch TV/ trying to sleep. Did you feel any pain in shoulder,
arm, wrist, hip or foot? How much did it hurt?”; (3) “Think of today,
when you move, walk or play. Did it hurt your shoulder, arm, wrist, hip or foot? How much did it
hurt?”; (4) “Think about today, when you were doing stretching exercises or physical therapy.
Did you feel any pain in the shoulder, arm, wrist, hip or foot? How much did it hurt?”; (5) “Think
of the most difficult movement that you can make with your shoulder, arm,
wrist, hip or foot. How much does it hurt when you try to do this movement?”.
The classification of limb distribution for the hypertonic (primarily spastic) form of CP was
accomplished in accordance with Surveillance of Cerebral Palsy in Europe registry classification
[20].
The ESWT consisted in 3 ESWT sessions, BTL-5000 unit, using the following parameters: energy
of 0.15mJ/mm2; total shots dose 500 shocks per each treated muscle; frequency 10 Hz; multi-
focus hand piece with 15 mm diameter. The treatment was not painful and no anesthesia was
needed. A descriptive statistical analysis of the quantitative parameters of mean, SD and paired-
sample t-test to compare the results before and after the treatment was carried out.

Otot : Triceps Suralis, Hamstring, Hip Adductor, Biceps Brachialis, Pronator Teres, Flexor Carpi
Outcome : MAS, QMFM.GG, QPS

J. Phys. Ther. Sci. 26: 1641–1647, 2014

2. Effects of Extracorporeal Shock Wave Therapy on Spasticity in Patients after
Brain Injury: A Meta-analysis
Jin-Youn Lee, MD1), Soo-Nyung Kim, MD, PhD2), In-Sik Lee, MD, PhD1), Heeyoune Jung, MD1), Kyeong-
Soo Lee, PT, MSc1), Seong-Eun Koh, MD, PhD1)*

1) Department of Rehabilitation Medicine, Konkuk University Medical Center and Konkuk University
School of Medicine, Konkuk University: 120-1 Neungdong-Ro, Gwangjin-Gu, Seoul 143-729, Republic of
Korea 2) Department of Obstetrics and Gynecology, Konkuk University Medical Center and Konkuk
University School of Medicine, Konkuk University, Republic of Korea

Abstract. [Purpose] The purpose of this meta-analysis was to assess the effects of extracorporeal shock
wave therapy (ESWT) on reducing spasticity immediately and 4 weeks after application of ESWT. [Subjects
and Methods] We searched PubMed, TCL, Embase, and Scopus from their inception dates through June
2013. The key words “muscle hypertonia OR spasticity” were used for spasticity, and the key words “shock
wave OR ESWT” were used for ESWT. Five studies were ultimately included in the meta-analysis. [Results]
The Modified Ashworth Scale (MAS) grade was significantly improved immediately after ESWT compared
with the baseline values (standardized mean difference [SMD], −0.792; 95% confidence interval [CI],
−1.001 to −0.583). The MAS grade at four weeks after ESWT was also significantly improved compared
with the baseline values (SMD, −0.735; 95% CI, −0.951 to −0.519). [Conclusion] ESWT has a significant
effect on improving spasticity. Further standardization of treatment protocols including treatment
intervals and intensities needs to be established and long-term follow up studies are needed. Key words:
Spasticity, Extracorporeal shock wave therapy, Meta-analysis
SUBJECTS AND METHODS
We searched PubMed, TCL, Embase, and Scopus from their inception dates through June 2013 to identify
interventional studies using ESWT to improve spasticity in patients with brain lesion. First, we searched
PubMed and TCL records using the following criteria: ((Muscle OR Muscular) AND (Spastic* OR
Hypertonia* OR Hypertonicit*)) OR (Muscle Tone Increased OR Spasticity) AND (Shock Wave* OR ESWT).
Second, we searched Embase using the following criteria: (muscle hypertonia’/exp OR (muscle OR
muscular AND (spastic* OR hypertonia* OR rigidit*)) OR (muscle AND tone AND increased) OR spastic*)
AND (shock wave’/exp OR shock wave* OR ‘ESWT’). Third, we searched Scopus using the following criteria:
((muscle OR muscular) AND (spastic* OR hypertonia* OR rigidit*)) AND (shock wave* OR “ESWT”).
Seventy-three studies were retrieved. Two reviewers working independently screened all the abstracts
and the titles for the candidate studies and discarded the studies in which extracorporeal shock waves
were used for different purposes other than spasticity. After the initial screening, they reviewed the full
text publications for eligibility, and disagreements between the two reviewers were resolved by
consensus. Only studies written in English were selected.

All of the studies using ESWT for the purpose of ameliorating spasticity in patients with any brain injury
were included. The studies involving other concomitant interventional procedures, such as botulinum
toxin injection, were excluded. We included the studies that provided both baseline and postprocedure
Modified Ashworth Scale (MAS) grades for selected muscles. The MAS grade was assessed immediately
after application of ESWT in all included studies. Among them, four studies suggested MAS grade which
was assessed 4 weeks after application of ESWT. The MAS grade ranged from 0 to 4, with 0 indicating no
increase in muscle tone and 4 indicating rigid in flexion and extension. From the selected studies, we
abstracted data regarding follow-up durations, pre- and postprocedure MAS grades, and MAS grades at
four weeks after ESWT, and compared them between time intervals. MAS grades were statistically
analyzed. Mean ± standard deviation values for pre- and postprocedure MAS grades and for the MAS
grades at four weeks after ESWT were provided in all studies. Heterogeneity refers to the differences
between studies in terms of methodological factors, such as use of blinding and concealment of allocation.
Significant statistical heterogeneity arising from methodological diversity or differences in outcome
assessments suggests that the studies are not all estimating the same quantity but does not necessarily
suggest that the true intervention effect varies. A number of options are available if statistical
heterogeneity is identified among a group of studies that would otherwise be considered suitable for a
meta analysis20) . Heterogeneity was calculated by the Cochrane Q statistic test and the I 2 test21) . The
I 2 test describes the rate of variation across studies due to heterogeneity rather than chance and ranges
from 0 (no heterogeneity) to 100 (maximum heterogeneity). All results are reported with 95% confidence
intervals (95% CI), and all p-values are two-tailed. When a significant heterogeneity among the outcomes
was found (I 2>50), the random effects model according to DerSimonian-Laird was used22) . This model
assumes that the true treatment effects in individual studies may be different from one another and that
these treatment effects are normally distributed. Those outcomes that did not present with heterogeneity
(I 2)